Rheumatoid arthritis (RA) resistant to monotherapy with either hydroxychloroquine or sulfasalazine^*

csDMARD: conventional synthetic disease-modifying antirheumatic drug; eGFR: estimated glomerular filtration rate; TNFi: tumor necrosis factor inhibitor.

* Treatment resistance is defined as one of the following: Failure to achieve remission/low disease activity after 3 to 4 months of therapy; a need for chronic glucocorticoids; multiple relapses (ie, ≥2 annually); or progressive erosive disease despite therapy. Refer to UpToDate content for additional discussion.

¶ Certolizumab is compatible for use throughout pregnancy. Refer to UpToDate content on rheumatoid arthritis and pregnancy for discussion of drug safety during lactation and pregnancy.

Δ eGFR is preferably determined using the 2021 CKD-EPI equation (calculator available); for information on use of eGFR for medication decisions refer to UpToDate content on assessment of kidney function, section on glomerular filtration rate for drug dosing.

◊ Refer to UpToDate topic for discussion of precautions and contraindications for these agents.

§ We do not use infliximab or adalimumab for monotherapy, due to their risk of anti-drug antibody formation. Refer to UpToDate content for discussion of specific TNFi therapeutic options and appropriate pre-treatment assessments.

¥ Adding methotrexate to the current csDMARD may facilitate transition to triple therapy, if necessary. Patients who achieve a stable remission on dual therapy can be transitioned to methotrexate monotherapy.